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Biomechanics Exam 3 (Ash) > Posterior Tibial Tendon Dysfunction > Flashcards

Posterior Tibial Tendon Dysfunction Flashcards

1
Q

in what type of foot is PTTD most likely to occur in

A
  • an already excessively pronated foot
  • the STJ axis is medial deviated causing more surface area available lateral to the STJ axis allowing ground reactive forces to cause a greater pronatory moment
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2
Q

treatment of PTTD

A

-address the medially deviated STJ axis by increasing the GRF medially to cause a supinatory moment at the STJ

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3
Q

PTTD is aka

A

adult acquired flat foot

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4
Q

acquired flat foot may occur as a result of

A

several conditions:

  • PTTD
  • fractured sustentaculum tali
  • calcaneal fractures
  • etc.
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5
Q

what ligaments are effected with acquired adult flat foot

A
  • spring ligament

- STJ interosseous lig

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6
Q

what ligaments may be effected with acquired adult flat foot

A
  • anterior portion of the deltoid
  • plantar MT ligaments
  • plantar naviculocuneiform lig
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7
Q

clinical testing for PTTD

A
  • test for strength and pain of the posterior tibial tendon
  • heel raise test
  • Hubscher maneuver (Jack test)
  • Hinterman test
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8
Q

Stage 1 (Johnson and Strom)

A
  • normal tendon length
  • mild degeneration
  • medial foot and ankle pain and swelling
  • mild weakness
  • no deformity
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9
Q

goal/ treatment for stage 1 PTTD

A

-reduce the rate and amount of pronation from heel strike to midstance (reduce the deceleration function of the TP)

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10
Q

what test should be used to determine what orthosis to precribe

A

-Hubscher maneuver and the 1st ray raise test (Hinterman) may be used to help decide if biomechanical control is indicated

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11
Q

Classification Systems of PTTD

A

Johnson and Strom(with Myerson modification)-based on clinical findings
Conti-based on MRI findings
Mueller- based on type/mechanism of tendon injury

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12
Q

for stage 1 PTTD what orthoses can be prescribed

A
  • function devices (cast in neutral position, for patients who have no deformity or changes in strength or flexibility)
  • UCBL devices (cast in neural or rectus depending on the flexibility of the flatfoot)
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13
Q

Stage 1 PTTD - orthotic modifications

A 
High medial flange
Lateral clip
Deep heel seat
Medial heel post flare
Extended medial heel post
Undercut lateral heel post
First ray cutout
Arch fill (on the device)
Wide width
Kirby skive
Blake inverted pour
Heel lift

*SHOULD INCLUDE A DEEP HEEL SEAT AND WIDE WIDTH

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14
Q

what does an extended medial heel post prolong

A

-the varus force at the RF

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15
Q

a medial heel flare may help

A

-decrease pronation over the top of the device

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16
Q

problems with a medial heel flare

A
  • limits shoe gear

- not undercutting heel post might be better

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17
Q

purpose of an undercut lateral heel post

A
  • decreases the pronatory lever arm

- may lead to lateral ankle sprain

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18
Q

how can a 1st ray cut out aid with PTTD

A
  • improves the lever arm of the PL

- the resupination force required of the TP may be decreased

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19
Q

stage 1 PTTD shoe modifications

A

Medial heel flare
Varus heel wedge
Heel lift
Extended heel counter/Heel counter reinforcement

20
Q

are shoe modifications adequate alone

A

no, but are best used in conjunction with orthoses or braces

21
Q

stage 1 PTTD bracing

A

Ankle stirrup types and over-the counter types of AFOs
Arizona brace
Marzano brace
Richie brace
Double upright hinged brace with an “orthopedic” shoe

22
Q

describe the Arizona brace

A

a leather and polypropylene AFO, cast in partial weightbearing on a 1/2 in. contour board
A gauntlet type of ankle brace (wrap around and tie on)

23
Q

when is an Arizona brace best used to treat PTTD

A
  • stages 1 & 2
  • maybe used for stage 3
  • 90% sucess rate for stage 1 & 2
24
Q

what is a Richie Brace

A
  • a functional orthosis incorporated in to an AFO

- cast in neutral position

25
Q

what is a Marzano Brace

A

a UCBL incorporated in to an AFO

26
Q

Stage 2 (Johnson and Strom)

A
  • attenuation of the tendon
  • increased pronation (calcaneal eversion/ FF abduction, increased FF supinatus)
  • decreased muscle strength of the posterior tibial tendon
27
Q

goal/treatment for stage 2 PTTD

A
  • return the foot to its more normal position

- prevent residual deformity

28
Q

Stage 2 PTTD Orthoses

A
  • functional with modifications; cast neutral or rectus

- UCBL; cast rectus

29
Q

stage 2 PTTD - orthotic modification

A 
-same as stage 1
High medial flange
Lateral clip
Deep heel seat
Medial heel post flare
Extended medial heel post
Undercut lateral heel post
First ray cutout
Arch fill (on the device)
Wide width
Kirby skive
Blake inverted pour
Heel lift

*SHOULD INCLUDE A DEEP HEEL SEAT AND WIDE WIDTH

30
Q

Stage 2 PTTD shoe modifications

A

Medial heel flare
Extended heel counter
Medial stabilizer
Varus wedge

31
Q

stage 2 PTTD Braces

A

Richie Brace
Arizona Brace
Marzano Brace

32
Q

Stage 3 (Johnson and Strom)

A

The severe pronatory deformity becomes rigid with associated rearfoot arthritis
Fixed everted position of the calcaneus
fixed forefoot supinatus deformity

33
Q

goal/treatment for stage 3 PTTD

A

-support the deformity and minimize compensatory changes proximal and distal to the deformity

34
Q

stage 3 PTTD orthoses

A
  • accommodative device (cast off weight bearing pronated or partial wt bearing; need more rigid material to prevent further collapse)
  • Shaffer plate (cast of wt bearing pronated or partial wt bearing)
35
Q

stage 3 PTTD orthotic modifications

A

-pocket for plantar prominences (usually for the navicular tuberosity)

36
Q

stage 3 PTTD shoe modifications

A
  • rocker sole
  • medial arch last expansion
  • medial stabilizer
37
Q

how do rocker soles aid PTTD

A
  • heel rocker helps control the rate of loading during the contact phase (decrease lever arm)
  • FF rocker eliminates the need for resupination
  • should be used with many of the AFOs
38
Q

how does a medial last expansion aid PTTD

A
  • increases contact medial to the STJ axis

- accommodates the convex medial foot shape associated with PTTD

39
Q

how does a medial stabilizer (buttress) aid PTTD

A

-reinforces the medial side of the shoe above the sole to prevent the foot from pronating over the shoe or an orthosis

40
Q

stage 3 PTTD braces

A

Richie Brace
Arizona Brace
Marzano Brace

41
Q

Stave 4 PTTD

A

in addition to the fixed valgus deformity at the STJ, the ankle functions in a valgus position

42
Q

treatment/goal for Stage 4

A

allow for a stable foot/ankle for ambulation

43
Q

stage 4 PTTD orthoses

A
  • a foot orthosis alone is not indicated

- a foot orthosis incorporated into a more proximal brace may be a possibility

44
Q

stave 4 PTTD orthotic modification

A

no applicable

45
Q

stage 4 PTTD shoe modifications

A
  • custom molded shoes
  • medial last expansion
  • medial buttress
  • rocker sole
46
Q

stage 4 PTTD braces

A

Patellar-tendon bearing brace

“Stage 4” Richie Brace

47
Q

In Conclusion

A

Aim the treatment at the stage of the deformity
Keep ALL aspects of the footwear in mind and do not hesitate to use a combination of orthoses, orthotic modifications, shoe modifications and/or braces
If the patient is potentially a surgical candidate, be willing to admit when it is time to give up and recommend surgery.

Biomechanics Exam 3 (Ash) (9 decks)

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